Membership Application

25 Kings Highway South
Westport, Connecticut
(203) 221-3280

I hereby enter my application for membership in Birchwood Country Club. I agree, if accepted as a member, to accept and abide by its by-laws, rules and regulations and to pay, when due, all financial obligations which can include operating and capital assessments.

Name of Primary Candidate

Name of Secondary Spouse Candidate

Date

Sponsor

Type of Membership

Regular	Racquets
Associate

Applications will not be considered unless completed in full. Dues and similar payments are not deductible or considered charitable contributions.

Primary Candidate

Full Name of Primary Candidate

Date of Birth

Place of Birth

Residence (A) and Dates

Primary Telephone No.

Residence (B) and Dates

Secondary Telephone No.

Cell Phone No.

Email Address

Business Firm Name

Business Address

Business Telephone No.

Dates Associated with Firm

Nature of Business

Occupation

Schools Attended and Dates

Brief Outline of Career

Names of Children, DOB, Residence

Parents' Names

Full Names of Brothers and Sisters (Including place of residence)

Previous Residences and Dates

Please list any current or prior club memberships and dates

Have you ever been denied admissions to any club and if so why?

Community Participation

Charitable Contributions (List only organizations to which you contribute on an ongoing basis)

Special Interest and/or Hobbies

Secondary Spouse Candidate

Full Name of Secondary Candidate